Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Rural and remote health research: key issues for health providers in southern Queensland

OBJECTIVE: To determine what community health service providers in rural southern Queensland considered were major issues affecting their efficacy. Results will inform the future research strategy of the Centre for Rural and Remote Area Health with the aim of addressing specific regional needs. DESIGN: Interactive research workshops. SETTING: Health providers and other key stakeholders. SUBJECTS: Participants from organisations directly involved with health care were complemented by representatives from local government, the police service and church groups. MAIN OUTCOME MEASURES: The workshops used the nominal group technique to identify what participants considered were key health issues in their locations. These issues were then prioritised by the participants. Thematic analysis of the issues generated a ranking of themes by importance. Results were compared with a similar exercise undertaken in 2003. RESULTS: Seventeen themes were identified, with workforce by far the major concern of health providers. Recruitment and retention of health workers were the principal issues of concern. The other four highest ranked themes across all workshops were mental health care, access to health services, perceptions and expectations of consumers, and interagency cooperation. The workshops provided important information to the Centre for Rural and Remote Area Health for developing research strategy. Additionally, new alliances among health providers were developed which will support sharing of information and resources. CONCLUSION: The workshops enabled organisations to meet and identify the key health issues and supported research planning. New alliances among health providers were forged, and collaborative research avenues are being explored. The workshop forum is an excellent means of information exchange.     

In their own words: young people's mental health in drought-affected rural and remote NSW

Objective: To record the drought‐related experiences of young people and to contrast these with their teachers' and other adults' observations. Design: Content analysis of issues and priorities raised in semistructured school‐based forums. Setting: Rural schools in NSW centres. Participants: Young people, their teachers and service providers. Intervention: Six youth and community forums organised under the Rural Adversity Mental Health Program. Results: Participants welcomed increased community connectedness in response to prolonged drought but reported that drought's mental health impact was mainly negative. Adults observed children's distress, wondering if anyone else noticed it. They witnessed young people worrying about their families, increasingly isolated, at risk of harm, unable to obtain help and facing educational and employment limitations. Young people disclosed many mental health and relationship difficulties at school and at home. They worried about their families, communities and futures and about money and being isolated. Conclusion: Adults and young people reported similar effects of prolonged drought on young people's mental health. But, while adults were more concerned with risks to young people (of harm, abuse, homelessness, problems with the law and constrained opportunities), young people were simply overwhelmed, wanting help for their immediate worries. They sought coordinated support within schools, schools working together, more information about mental health and where to seek help for them and their friends, and support people who understood drought and rural circumstances and on whose discretion they could rely. Mental health programs that are developed in and for metropolitan contexts need to be adapted before being deployed in rural settings.     

Continuum of care and the antenatal record in rural New South Wales

Objective: The aim of the study was to determine the effect of the woman held antenatal record card (PNC2) on the continuity of maternity care received when presenting to the acute rural setting for clinical assessment. Design: Qualitative, open‐ended questionnaires. Setting: Rural New South Wales public hospital. Subjects: Maternity consumers, 50 women who were inpatients receiving antenatal or postnatal care between August and October 1998. A stratified sample of healthcare professionals employed by the service, 12 midwives and 13 general practitioners. Main outcome measure: The self reported use of the antenatal card and the viewed effects of the card on the continuity of healthcare received. Results: The study identified a significant difference between the responding professionals (93%) positive perception of the effect of the PNC2 on the women's pregnancy continuum of care and the maternity consumer (36%), who felt it bore little impact on their care. The study findings suggested a lack of compliance and standardisation in usage of the antenatal card negated any flow on effects for the women. Conclusions: The intended purposes of the PNC2 were compromised in this rural setting. The study recommends that stakeholders in rural maternity care be accountable for examining the benefits and barriers of their antenatal practices, that the rural community's expectations of ‘continuity of maternity care’ are sought and that there should be a review of the available models of rural antenatal care. What is already known: The woman held antenatal record has been reported to be an effective approach for enabling consumers to participate in their maternity care, whilst also address the concerns of continuity, safety and information sharing. This form of medical record has been strongly supported by the National Health and Medical Research Council and NSW Health as a professional and consumer friendly strategy. The usage or the effects of the antenatal record in rural New South Wales settings have yet to be widely evaluated. What this study adds: The study's questionnaire responses identified that the antenatal record may have met the needs of rural health professionals, however, the maternity care consumers were unaware of these benefits. The study suggests that the antenatal record was operationalised at the discretion and for the convenience of the rural health care professional. Identifying rural communities perceptions of continuity of care and the need to explore models of care that promote continuity in rural areas, where significant findings of the study.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

Health Care Services for HIV-Positive Substance Abusers in a Rural Setting: An Innovative Program

ABSTRACT

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care–related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

Characterization of Rural Mental Health Service Systems

This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on nonspecialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on nonmental health agencies, rural mental health agencies are more interdependent.     

Rapid change, climate adversity and the next 'big dry': older farmers' mental health

Objective: To describe the experiences of older farmers in the face of prolonged drought and rapid change. Design: Content analysis of issues and priorities raised in semi‐structured community forums. Setting: Rural centres in NSW. Participants: One hundred and fifty older farmers, their families, Industry and Investment NSW, rural financial and mental health services, the Country Women's Association and other non‐government agencies. Intervention: Five public forums organised under the Rural Adversity Mental Health Program. Results: Prolonged drought caused pressures on farmers that compounded the usual stresses of farming and of ageing. These were experienced in the context of rapid social and industry change, fuel price volatility and the insidious threat of climate change. Three main themes were articulated: loss, government compliance pressures and difficulties accessing and/or inappropriate services. Conclusion: Older farmers felt an overwhelming sense of loss: of profitability and professional success, community status, physical well‐being and comfort, the ability to participate in the modern world and, above all, of relationships (partners, children and friends moving away). They interpreted government compliance requirements as evidence of community and government loss of trust in famers. They resisted using the few mental health services that might be available, fearing being labelled as ‘crazy’ and discouraged by the culturally inappropriate way in which services were offered. Older farmers would benefit from joint services related to health and well‐being simultaneously with modern business management offered in trusted, comfortable settings.     

Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales,Australia: A step towards explaining high CAM use in rural health?

Objective: Complementary and alternative medicine (CAM) use is high in rural health and an agenda for research in the geography of CAM has been outlined. Unfortunately, no studies to date have mapped the geographic distribution of CAM practitioners in rural areas. For the first time we investigate CAM practitioner distributions across a large district/region in rural Australia. Setting and design: A CAM infrastructure audit of practitioners was performed in rural Divisions of General Practice in New South Wales, Australia. Results: CAM providers form a significant part of the health care system in rural New South Wales with substantial representation across all degrees of rurality and in both under‐serviced and well‐serviced areas. CAM practitioners outnumbered GPs in four NSW Divisions of General Practice and in no Division numbered less than half of the total number of GPs. Conclusions: Given the challenges of access to and recruitment and retention of conventional health care providers in rural settings and the significant presence of CAM practitioners, it is possible to consider such practitioners as an untapped resource in rural health care delivery. Assuming appropriate regulatory and quality standards are in place this resource should attract careful attention as part of future rural health policy and planning. The significant presence and high prevalence of use of CAM practitioners should also serve as an impetus to reform CAM service delivery in Australia.     

Service Use of Rural and Urban Medicaid Beneficiaries Suffering From Depression: The Role of Supply

Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people suffering from depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed carefor physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine suffering from depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)--and Supplemental Security Income (SSI)--beneficiaries suffering from depression rely more on mental health than on general health care providers to receive ambulatory mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of primary care providers and to study the role of supply across multiple states.     

Symptoms,functioning and quality of life after treatment in a residential sub‐acute mental health service in Australia

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery‐focused, sub‐acute service, in Australia. Clients were either step‐up clients, entering the service directly from the community, or step‐down clients who were transitioning from an inpatient unit to home. During the 30‐month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis‐32) and service providers completed the Life Skills Profile‐16 and Health of the Nations Outcome Scales. Follow‐up data 3 months after exit were available for 12 clients, including the Basis‐32 and a self‐report measure of quality of life (Assessment of Quality of Life 8‐dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self‐care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub‐acute service, step‐up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step‐down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub‐acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.     

NATIONAL RURAL HEALTH POLICY AND THE ROLE OF THE NATIONAL RURAL HEALTH CONFERENCES

ABSTRACT: The biennial National Rural Health Conference has become an essential feature on the calendar of events for rural and remote health professionals, researchers, public servants and consumers. Since the first conference held in 1991, attendance has grown significantly, factors hindering the achievement of optimal health for all rural and remote Australia have been clearly identified, and recommendations for action have been endorsed by the broad rural health constituency. These recommendations have provided valuable input to the National Rural Health Strategy and many programs and policies of Commonwealth and State departments of health. Significantly, too, the first four conferences have facilitated greater collaboration among rural and remote health professionals and provided a major catalyst in fostering cooperation between consumers, health workers, service providers and governments.     

Improving mental health capacity in rural communities: mental health first aid delivery in drought-affected rural New South Wales

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought‐affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems. Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front‐line workers from agricultural‐related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families. Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence‐based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help. Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.     

Health care services for HIV-positive substance abusers in a rural setting: an innovative program

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care-related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

The Health of Caregiving Grandmothers: A Rural‐Urban Comparison

Purpose: The purpose of this study was to compare the characteristics of rural versus urban caregiving grandmothers along with their physical and mental health status. Methods: A secondary analysis of data produced from the first wave of a longitudinal study of 485 Ohio grandmothers was conducted. Health status was measured using the SF‐36 Health Survey and the 20‐item CES‐D depression scale. Rural‐urban classification was made using Rural Urban Commuting Area (RUCA) codes based on resident ZIP codes, identifying 97 rural and 388 urban grandmothers in the sample. Findings: The rural and urban grandmothers were similar in age, educational level and employment status; however, 90% of the rural grandmothers compared with 60% of the urban grandmothers were white. Rural grandmothers were most likely to have traditional nonresidential relationships with their grandchildren. Approximately 38% of both the rural and urban grandmothers served as primary caregivers for their grandchildren, but a lower percentage of rural grandmothers lived in multigenerational homes. There was no significant difference between the rural and urban grandmothers in relation to physical or mental health. Among rural grandmothers, primary caregivers had significantly lower levels of mental health compared with the other caregiver groups. Conclusions: These findings suggest that rural and urban grandmothers have similar levels of physical and mental health, despite differences in demographics and caregiving arrangements. Health promotion efforts with rural caregiving grandparents are indicated, addressing both mental and physical health.     

If the land's sick, we're sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well‐being, and of possible adaptive strategies. Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums. Setting: Rural centres across NSW. Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions. Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well‐being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts. Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought‐induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well‐being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well‐being.     

Balancing hospital and community treatment: effectiveness of an extended-hours community mental health team in a semi-rural region of australia

Objective: To examine the effectiveness of the introduction of a community mental health team on consumer psychosocial outcomes. Design: Longitudinal panel design. Setting: District general hospital in a semi‐rural region of Australia. Numbers: Two matched groups (n = 37 in each group) Main outcome measure: These included: Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), Rosenberg Self‐Esteem, Life Skills Profile as well as self‐report. Results: The study found that the introduction of the new service resulted in few significant differences in consumer outcomes. Conclusions: The paper argues that because the state was the only specialist mental health service provider and it was unable to offer assertive community treatment, hospital care remained central. Evidence that a substantial proportion of consumers and carers preferred hospital to community care is placed against this background. The paper argues that in regions like these, where community‐based services are likely to remain underdeveloped, it may be best to maintain quality hospital services and to target community services more precisely on what is achievable rather than developing community services at the expense of hospital care. What is already known: Studies on the efficacy of assertive community treatment suggest that it can lead to improved consumer outcomes. However, these studies are usually in urban settings and involve experimental teams. In many rural and regional areas community treatment teams offer standard rather than assertive community care. It is therefore important to investigate the effectiveness of community treatment teams in rural and regional Australia. What this study adds: This study suggests that in rural and regional areas characterised by limited resources, it is too much to expect community treatment teams to have a measurable impact on consumer outcomes. In these settings hospital care remains at the heart of the service. This means that regions such as these need to focus their community services on what is achievable given the level of resources and social ecology. For example, they may need to consider offering either crisis intervention or rehabilitation services and to rely on innovations, such as telehealth or strategic alliances with other service providers to fill the gap.     

The adoption and use of health information technology in rural areas: results of a national survey

Context: Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural‐urban differences in HIT adoption at the national level. Purpose: To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption. Methods: A national mail survey of 5,200 primary care offices, stratified by rurality using Rural‐Urban Commuting Area categories, was conducted in 2007‐2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans. Results: A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02). Conclusions: HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.     

Mental health of farmers in Southern Queensland: Issues and support

Objective: To inform the development of an initiative designed to support the mental well‐being of farmers in Queensland. Design: Interactive focus groups. Setting: Rural and remote Queensland. Participants: Health professionals, farmers and representatives of organisations and agencies working with farmers. Main outcome measures: Determination of factors contributing to the declining mental health of rural landholders. Content material for inclusion into mental health first aid programs held for field officers. Results: Key areas identified to contribute to the decline in mental health of farmers were: increasing isolation in its varying forms, the ongoing drought, increased government regulations and widening of the schism between urban and rural Australians. The issues that affect farmers are recognised to have a ‘knock‐on’ effect on the people who interact with them. In particular, rural support organisations are concerned for the well‐being of their staff, prompting some to begin to put protocols in place to address their staff need for mental health support. Additional mental health training of field officers that involves awareness, recognition, communication skills, understanding and empathy was recognised by participants to be beneficial. Conclusion: Training of field officers was considered to be of benefit to the support of farmers. An understanding of the various and diverse issues that rural landholders face should be a fundamental component of that training.